NOTICE OF GROUP HEALTH PLAN'S EXEMPTION FROM THE MENTAL HEALTH PARITY ACT
DESCRIPTION OF THE ONE PERCENT INCREASED COST EXEMPTION -- This notice is required to be provided to you under the requirements of the Mental Health Parity Act of 1996 (MHPA) because the group health plan identified in Line 1 below is claiming the one percent increased cost exemption from the requirements of MHPA. Under MHPA, a group health plan offering both medical/surgical and mental health benefits generally can no longer set annual or aggregate lifetime dollar limits on mental health benefits that are lower than any such dollar limits for medical/surgical benefits. In addition, a plan that does not impose an annual or aggregate lifetime dollar limit on medical/surgical benefits generally may not impose such a limit on mental health benefits. However, a group health plan can claim an exemption from these requirements if the plan's costs increase one percent or more due to the application of MHPA's requirements.
This notice is to inform you that the group health plan identified in Line 1 below is claiming the exemption from the requirements of MHPA. The exemption is effective as of the date identified in Line 4 below. Since benefits under your group health plan may change as of the date identified in Line 4 it is important that you contact your plan administrator or the plan representative identified in Line 5 below to see how your benefits may be affected as a result of your group health plan's election of this exemption from the requirements of MHPA.
Upon submission of this notice by you (or your representative) to the plan administrator or the person identified in Line 5 below, the plan will provide you or your representative, free of charge, a summary of the information upon which the plan's exemption is based.
The Secretaries have designated the following addresses for delivery of exemption notices:
CHURCH PLANS should send exemption notices to the Department of the Treasury at:
Office of the Assistant Commissioner, Examination
Examination Programs CP:EX:E
1111 Constitution Avenue, NW
Washington, D.C. 20224
Attention: MHPA one percent cost exemption notice
TITLE I ERISA PLANS should exemption notices to the Department of Labor at:
Public Documents Room
Pension and Welfare Benefits Administration
U.S. Department of Labor
Room N-5638
200 Constitution Avenue, NW
Washington, D.C. 20210
Attention: MHPA one percent cost exemption notice
NON-FEDERAL GOVERNMENTAL PLANS should send exemption notices to the Department of Health and Human Services at:
the Centers for Medicare and Medicaid Services
7500 Security Boulevard
Baltimore, MD 21244-1850
Attention: Insurance Standards: Exemptions
NOTICE OF GROUP HEALTH PLAN'S USE OF TRANSITION PERIOD
* IMPORTANT -- This notice is required to be provided if a group health plan uses the transition period under the requirements of the Mental Health Parity Act (MHPA). Under MHPA, a group health plan offering both medical/surgical and mental health benefits generally can no longer set annual or aggregate lifetime dollar limits on mental health benefits that are lower than any such dollar limits for medical/surgical benefits. In addition, a plan that does not impose an annual or aggregate lifetime dollar limit on medical/surgical benefits generally may not impose such a limit on mental health benefits. However, a group health plan can claim an exemption from these requirements if the plan's costs increase one percent or more due to the application of MHPA's requirements. Under MHPA, a plan that claims the one percent increased cost exemption prior to the issuance of the MHPA interim regulations based on assumptions inconsistent with the MHPA interim regulations may delay compliance with the parity requirements of MHPA until a date no later than March 31, 1998.
This notice is to inform you that the plan is utilizing the MHPA transition period and that the plan is delaying compliance with the parity requirements of MHPA until a time no later than March 31, 1998.
Name of the group health plan and the plan number (PN):
Name, address, and telephone number of plan administrator responsible for providing this notice:
For single-employer plans, the name, address, telephone number, (if different from Line 2), and employer identification number (EIN) of the employer sponsoring the group health plan:
For further information, call:
Signature of plan administrator: _____________________________________ Date:_____________
The Secretaries have designated the following addresses for delivery of the transition notices:
CHURCH PLANS should send transition notices to the Department of the Treasury at:
Office of the Assistant Commissioner, Examination
Examination Programs [mail code]
1111 Constitution Avenue, NW
Washington, D.C. 20224
Attention: MHPA transition period notice
TITLE I ERISA PLANS should send transition notices to the Department of Labor at:
Public Documents Room
Pension and Welfare Benefits Administration
U.S. Department of Labor
Room N-5638
200 Constitution Avenue, NW
Washington, D.C. 20210
Attention: MHPA transition period notice
NON-FEDERAL GOVERNMENTAL PLANS should send transition notices to the Department of Health and Human Services at:
the Centers for Medicare and Medicaid Services
7500 Security Boulevard
Baltimore, MD 21244-1850
Attention: Insurance Standards: Exemptions
